Aim
Develop a comprehensive end of treatment survivorship program for patients with early breast cancer. Demonstrate, based upon key strategies and learning, this model of care can be transferred, adapted and implemented according to the individual needs of an organisation.
Method
From 2010 three major metropolitan Melbourne based Breast Services developed a comprehensive survivorship program for women with early breast cancer who had completed their active hospital based treatment. Working collaboratively with Primary Health Networks and a community based peer support service this work was funded by the Victorian Department of Health & Human Services (DHHS). A nurse-led consultation, survivorship care plan & follow-up guidelines were developed, implemented & evaluated.
Based upon the establishment of this as a sustainable model of survivorship care, the DHHS extended funding to other Melbourne Metropolitan Breast Services. In addition, one of the lead sites provided mentorship, transfer of knowledge, processes and resources developed.
Results
Across the four sites more than 760 nurse-led consultations have been completed. Evaluation of patients, GPs and specialists involved identified overwhelmingly positive feedback including improved, individualised, consistent & co-ordinated follow-up care. Early transition to shared primary and hospital based follow-up care is achieved which increases capacity for new and complex review patients within the specialist outpatient service.
Conclusion
The survivorship program is being embedded as part of routine practice at the listed sites, and demonstrates that this model of care can be transferred across Breast Services. It is a model that can also be adapted to other tumour streams. Fostering collaborative partnerships between acute services, primary care, consumers and community based services enables a comprehensive approach to developing new models of survivorship care. Streamlining processes and sharing of knowledge and resources is an important part of developing a sustainable and transferable model of care.